=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407267123
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JESSICA R. BERTOGLIO, DDS, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2014
-----------------------------------------------------
Last Update Date | 05/15/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3049 N BARRINGTON RD
-----------------------------------------------------
City | HOFFMAN ESTATES
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60192-2024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-893-9099
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3049 N BARRINGTON RD
-----------------------------------------------------
City | HOFFMAN ESTATES
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60192-2024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-893-9099
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST/OWNER
-----------------------------------------------------
Name | DR. JESSICA R. BERTOGLIO
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 847-893-9099
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 019028145
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------